Provider Demographics
NPI:1790487718
Name:QUEBEDEAU, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:QUEBEDEAU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4436 MANGUM DR
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-2113
Mailing Address - Country:US
Mailing Address - Phone:601-586-7070
Mailing Address - Fax:
Practice Address - Street 1:4436 MANGUM DR
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-2113
Practice Address - Country:US
Practice Address - Phone:601-586-7070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-21
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS905849363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care